Provider Demographics
NPI: | 1639599343 |
---|---|
Name: | ROSHUNDRA GRAHAM |
Entity Type: | Organization |
Organization Name: | ROSHUNDRA GRAHAM |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CLINICAL SOCIAL WORKER |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | ROSHUNDRA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GRAHAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LMSW |
Authorized Official - Phone: | 313-410-7380 |
Mailing Address - Street 1: | 29197 YORKSHIRE LN |
Mailing Address - Street 2: | |
Mailing Address - City: | WARREN |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48088-3784 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 313-410-7380 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 24801 5 MILE RD |
Practice Address - Street 2: | |
Practice Address - City: | REDFORD |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48239-3655 |
Practice Address - Country: | US |
Practice Address - Phone: | 313-255-2650 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-04-21 |
Last Update Date: | 2014-12-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 6801085573 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |